MOTOR VEHICLE CLAIM FORM

Transcription

1 SURA AUSTRALIAN BUS AND COACH LEVEL 14 / 141 WALKER ST NORTH SYDNEY NSW 2060 P O BOX 1813 NORTH SYDNEY NSW 2059 TELEPHONE SURA.COM.AU MOTOR VEHICLE CLAIM FORM IN THE EVENT OF A CLAIM Take precautions to ensure that no further damage or loss occurs to the motor vehicle. Where possible have the motor vehicle moved to a secure location if not drivable. Obtain one repair quotation. This Claim Form should be completed and returned to your Broker as soon as possible with any relevant photos and attachments. Contact your Broker if you are unsure about any matters in relation to the completion of this Claim Form. POLICY DETAILS Insured: Policy Number: ABN: To what extent can you claim an input tax credit on your motor vehicle insurance premiums? % To what extent can you claim an input tax credit on the vehicle which is the subject of this claim? % Contact Name: Fax: Number of Employees INSURED VEHICLE DETAILS Year: Make: Model: Registration No: Vin/Engine No: Colour: For what purpose was the vehicle being used at time of accident? School Bus General Charter/Intra State Tours Local Charter Interstate Tours Airport, Hotel, Motel Transfers Route Service Hotel/Club Shuttle Bus Scheduled Intercapital Express Self/Drive Hire Private Intra State Express (Ie: Countrylink, Vline Services) Other, Please Specify: 1

2 INSURED VEHICLE DETAILS (CONTINUED) Registered Owner: Do you owe money on your vehicle? (Only answer if insured vehicle is a potential write off/total loss/stolen) Yes No If YES give details: Name of Lender: Account Details: DRIVER DETAILS Name of Driver: Postcode: Relationship to insured (ie. insured, employee, hirer, relative, lease driver etc): Licence No: Expiry Date: DOB: How long has the driver been licensed for this type of vehicle? Years Was the vehicle being used with the insured s knowledge and consent? Yes No If YES reason for use? (Business, Private etc.) Did the driver drink alcohol or take drugs in the 12 hours prior to the accident? Yes No If YES reason for use? (Business, Private etc.) Did the driver undergo a breath test, breath analysis or blood test? Yes No What was the reading? (Please attach copy of the certificate) 2

3 ACCIDENT OR THEFT DETAILS Date of accident / theft: / / Day of week: Time: 24hr Where did the accident happen? Postcode: Weather conditions? Sunshine Rain Other (Please Advise): Road Surface: Dry Wet Sealed Unsealed Flat Uphill Downhill Road Type: Straight Curved Left Turn Right Turn At the time of the accident the insured s vehicle was: Parked Stationary Moving Speed: Kph At the time of the accident the other vehicle/s were: Parked Stationary Moving Speed: Kph Traffic Controls: None Stop Sign Roundabout Give Way Sign If traffic lights, were they Green Amber Other Party? Red Against You? What lights, if any were being used by you? Other Party? Accident: Describe events before, during and after the accident (include no. of lanes, speed, parked, reversing) Who was at fault? Given Names: Is there any CCTV footage available? (Please retain copy in case of dispute in liability.) Yes No 3

4 SKETCH DIAGRAM OF ACCIDENT 1. Name Streets 2. Direction of travel indicated by arrow 3. Your Vehicle 4. Other Vehicle 5. Show: North, South, East and West, Traffic signs, ie: Stop, Give Way, Roundabout etc. THEFT Describe events from time parked until discovered missing (include who made discovery and any action taken) 4

5 DAMAGE TO YOUR VEHICLE Are you claiming for the damage to your vehicle? Yes No Was the vehicle towed? Yes No If yes give details: Name of tow company: Where was it towed? Distance towed: kms Where is vehicle now? Estimated cost of repairs: $ Show on the Diagram where damage to Your Vehicle occurred: 5

6 OTHER VEHICLE Make: Model: Year: Registration No: Colour OWNER OF OTHER VEHICLE Insurance Co: Policy No: DRIVER OF OTHER VEHICLE Date Of Birth: Drivers Licence No: Was The Owner In The Vehicle At The Time Of The Accident? Yes No IF THERE IS MORE THAN ONE VEHICLE INVOLVED PLEASE ATTACH DETAILS SKETCH DIAGRAM: Shade in damage to Other Vehicle. Indicate point of Impact (X). 6

7 OTHER PARTIES POLICE Did police attend the incident scene? Yes No OR did you report the incident to the police? Yes No Name: Station: Rank: Police event number: Date of report: / / Name of person to be charged or cautioned: Nature of charge or caution: WITNESS (ES) DETAILS Private: Was this witness in the insured vehicle? Yes No Private: Was this witness in the insured vehicle? Yes No 7

8 ELECTRONIC FUNDS TRANSFER Following SURA Australian Bus and Coach's approval of your claim, your claims benefit can be transferred directly into your bank account. Please provide the following details: Name of Financial Institution: Account Name: Bank Swift Code (BSB): Account Number: AGENT OF THE INSURERS SURA Australian Bus and Coach acts as an agent of the Insurer and not as your agent when issuing insurance policies, dealing with or settling any claims. This is an important document please read it carefully. PRIVACY STATEMENT We are committed to protecting your privacy in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles (APPs), which will ensure the privacy and security of your personal information. The information provided in this document and any other documents provided to us will be dealt with in accordance with our Privacy Policy. By executing this document you consent to collection, use and disclosure of your personal information in accordance with our Privacy Policy. If you do not provide the personal information requested or consent to its use and disclosure in accordance with our Privacy Policy, your application for insurance may not be accepted, we may not be able to administer your services/products, or you may be in breach of your duty of disclosure. Our Privacy Policy explains how we collect, use, disclose and handle your personal information including transfer overseas and provision to necessary third parties as well as your rights to access and correct your personal information and make a complaint for any breach of the APPs. A copy of our Privacy Policy is located on our website at www. sura.com.au Please access and read this policy. COMPLAINTS AND DISPUTES RESOLUTION We view seriously any complaint made about Our products or services and will deal with it promptly and fairly. If You have a complaint please first try to resolve it by contacting the relevant member of Our staff. If the matter is still not resolved, please then contact Our Internal Disputes Resolution Officer on (02) , or by at IDR@SURA.com.au or by writing to Us at the address for SURA given above. They will seek to resolve the matter in accordance with the General Insurance Code of Practice and Our Dispute Resolution procedures. You can contact Us if You want more information on Our procedures. If You are a natural person or a small business, and You are not satisfied with the final decision, You may wish to contact the Australian Financial Complaints Authority (AFCA). The AFCA is a free independent external disputes resolution service provided to customers to review and resolve complaints where We have been unable to satisfy Your concerns. For further details You can visit their website at or contact them: Australian Financial Complaints Authority PO Box 3 Melbourne, VIC, 3001 Telephone: info@afca.org.au If you have any queries about how we handle your personal information or would prefer to have a copy of our Privacy Policy mailed to you, please ask us. If you wish to access your file please ask us. GENERAL INSURANCE CODE OF PRACTICE We proudly support the General Insurance Code of Practice (the Code ). The purpose of the Code is to raise the standards of practice and service in the general insurance industry. For further information on the Code, please visit www. codeofpractice.com.au or alternatively you can request a brochure on the Code from SURA Australian Bus and Coach. 8

9 DECLARATION AND AUTHORISATION I/We declare that to the best of my knowledge and belief, the information provided on this claim form and in any attached documentation is true and correct and that I/We have not withheld any relevant information. I/We consent to SURA Australian Bus and Coach and/or its agent using the personal information I/We have provided for the purpose of processing my claim. I/We understand that if I/We choose not to provide the required details, this is my/our choice; however, SURA Australian Bus and Coach and/or its agent may not be able to process my/our claim. I/We consent to SURA Australian Bus and Coach and/or its agent disclosing my/our personal information to other insurers, an insurance reference service, claims adjusters, lawyers and other consultants or as required by law. I/We also consent to SURA Australian Bus and Coach and/or its agent disclosing my/our personal information to and/or collecting additional information about me/us, from investigators or legal advisors. I/We acknowledge that I/We have read and understood the Privacy Statement and consent to the collection, storage, use and disclosure of personal and sensitive information to all persons affected by this claim. I/We acknowledge that if I/We do not agree to the collection of this personal information then SURA Australian Bus and Coach and/or its agent will be unable to process my/our claim. I/We authorise SURA Australian Bus and Coach or its agent to give to and obtain from other insurers, insurance reference bureaus and credit reporting agencies any information relating to the insured s credit or insurance history as well as insurance claims information obtained during the course of this contract. Signature of insured: Date: Name: (please print) Signature of driver: Date: Name: (please print) 9